Regulation 40 - Unrepresented
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Please type the name of the doctor who will be evaluating you *
Regulation Terms
Pursuant to QME regulation 40, you are being advised that:
(a) You are entitled to ask the QME about any matter concerning the evaluation
process
(b) You may discontinue this evaluation at any time based on good cause. Good
cause is defined as (A) discriminatory conduct by the evaluator towards you
based on race, sex, national origin, religion, or sexual preference or (B)
abusive, hostile, or rude behavior that clearly demonstrates a bias against
injured workers or (C) you feel the QME has requested you to submit to an
unnecessary exam or procedure.
By typing my full name below, I am digitally signing that I have read, understand and agree to all of the above terms *
Today’s Date *
MM
/
DD
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YYYY
By typing my full name below, I am digitally signing I request that the QME evaluating me today address the issue of medical causation. This constitutes a written request pursuant to CCR 9795, ML103(6).
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